What is the most appropriate once‑daily triple inhaler for an 89‑year‑old female with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF)?

Recommended Triple Inhaler for COPD with CHF

For your 89-year-old patient with COPD and CHF, prescribe a once-daily single-inhaler triple therapy (LAMA/LABA/ICS) such as fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta), which provides superior mortality reduction, fewer exacerbations, and improved quality of life compared to dual therapy, with acceptable cardiovascular safety in heart failure patients. 1

Why Triple Therapy is Essential

The 2023 Canadian Thoracic Society guidelines make a strong recommendation for LAMA/LABA/ICS triple combination therapy over dual therapy specifically to reduce mortality in patients with:

• High symptom burden (mMRC ≥2 or CAT ≥10)
• FEV1 <80% predicted
• High exacerbation risk (≥2 moderate or ≥1 severe exacerbation in past year) 1

Triple therapy provides greater benefits than dual therapy including:

• Significant reduction in all-cause mortality (independently adjudicated with lower rates of both respiratory and cardiovascular death) 1
• 15-25% reduction in moderate-to-severe exacerbations 2
• 34% reduction in severe exacerbations requiring hospitalization 2
• Improved dyspnea, health status, and lung function 1

Specific Product Selection

Single-inhaler triple therapy (SITT) is strongly preferred over multiple inhalers due to increased adherence, reduced errors in inhaler technique, and potentially increased benefits. 1

Once-Daily Options:

• Fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta): The only once-daily SITT, which offers superior convenience for elderly patients 3
• This formulation demonstrated a 0.85 rate ratio for exacerbations vs ICS/LABA and 0.75 vs LAMA/LABA 2

Alternative if Once-Daily Not Available:

• Budesonide/glycopyrronium/formoterol (Breztri Aerosphere) - dosed twice daily 4, 5

Addressing the CHF Comorbidity

The cardiovascular safety profile supports triple therapy use in CHF patients:

• Independent adjudication in large trials confirmed lower rates of cardiovascular death with triple therapy 1
• LAMA/LABA bronchodilators are being actively studied for potential benefits in HF with COPD, with emerging evidence of safety 6
• The SUMMIT trial specifically enrolled patients with heightened cardiovascular risk and found acceptable safety 1

Critical caveat: Avoid short-acting β-agonists in high doses if your patient has unstable CHF, but long-acting agents in triple therapy are safe. 6

ICS Dose Considerations

Use moderate-dose ICS (not high-dose):

• The ETHOS trial showed no significant difference in exacerbation reduction between budesonide 160 mcg vs 320 mcg (rate ratio 1.00; 95% CI 0.91-1.10) 4
• However, mortality benefit favored the moderate dose (320 mcg equivalent) 4
• The dose-response curve for ICS in COPD is relatively flat—higher doses increase adverse effects without proportional benefit 4, 7

Essential Safety Monitoring

Pneumonia risk with ICS-containing regimens:

• 4% increased absolute risk compared to bronchodilators alone 4
• Number needed to harm: 33 patients treated for 1 year to cause one pneumonia 4, 7
• Number needed to treat: 4 patients for 1 year to prevent one moderate-to-severe exacerbation 4

Monitor closely if your patient has:

• Current smoking status
• Age ≥55 years (your patient is 89)
• Prior exacerbations or pneumonia
• BMI <25 kg/m²
• Severe airflow limitation 4, 7

Risk mitigation:

• Instruct patient to rinse mouth with water without swallowing after each inhalation to reduce oral candidiasis risk 4
• Monitor for signs/symptoms of pneumonia at each visit 7

What NOT to Do

Never use ICS as monotherapy in COPD—it should only be used in combination with long-acting bronchodilators. 4, 7

Never step down from triple therapy to dual therapy in a patient at high exacerbation risk—withdrawing ICS increases moderate-severe exacerbation risk, particularly in patients with blood eosinophils ≥300 cells/μL. 4, 7

Do not add theophylline to triple therapy—guidelines recommend against this due to low certainty of benefit, high risk of adverse events, and significant drug interactions. 7

Avoid beta-blocking agents (including eyedrop formulations) in COPD patients when possible. 1

Implementation Strategy

1. Verify inhaler technique before prescribing and recheck at follow-up visits—76% of COPD patients make important errors with metered-dose inhalers 1

2. Prescribe as-needed short-acting bronchodilator (SABD) for breakthrough symptoms in addition to triple therapy 1

3. Consider blood eosinophil count if available—patients with eosinophils ≥300 cells/mL derive particular benefit from ICS-containing regimens 4, 7

4. Schedule follow-up at 4-6 weeks to assess response, adherence, and adverse effects